I was very fortunate to be hosted by Sarah Kroman – “a GLA:D® super-user” in her family clinic in Faaborg , Denmark.

For those people who are not aware of the GLA:D® program it is an evidence based, physiotherapist supervised, safe, group exercise and education program for people with knee and hip osteoarthritis, designed by Ewa Roos and Soren Skou from University of Southern Denmark, Denmark. It has pre and post intervention measures of knee / hip function collected on an electronic register. Research in Denmark has shown the GLA:D® program reduces pain by 25%, reduces the intake of pain killers and shown increased levels of physical activity 12 months after starting the patient education plus 12 session exercise program.

It has been running in Denmark for 5 years now with over 30,000 patients having participated in the program. The GLA:D® program is now being taught in China, Canada and more recently in Australia. There are now 40 centres around Australia offering the GLA:D® program. You can find your local GLA:D® provider in Australia here.

For those people who are now questioning how this fits into my ACL Churchill Fellowship project; Following on from my last blog where I wrote about early degenerative changes post ACL injury, unfortunately 10-20 years following an ACL injury, about 50% of patients will have knee osteoarthritis, despite the management option chosen (non-operative or operative).

The Clinical Translator:

Research evidence has been telling us for years that exercise is a safe and effective intervention for the symptom management of osteoarthritis. Despite this, issues of patient compliance have been barriers to effective implementation/success of this modality. The GLA:D program is a very user friendly, safe, evidence based group 12 session exercise program which increases the success of exercise therapy outcomes. An accompanying education program teaches patients about osteoarthrosis and symptom management. As a GLA:D facilitator in Australia it is easy to administer, regress and progress even for more junior physiotherapist’s because it is a standardised program which can be individualised as required, within specific guidelines.

Physiotherapists teaching the GLA:D program have all undergone a standardised 2 day training program – see https://gladaustralia.com.au. If you are a physiotherapist interested in being accredited to teach the GLA:D program. It is appropriate for a broad range of patients with hip and knee osteoarthritis. My patients in Australia report it is fun, socially engaging and cost effective. Research has shown GLA:D users report high levels of satisfaction, use less pain medication, less sick leave and have been able to delay surgical intervention due to symptom management.

This is intended as an aid to the clinician to translate research findings into clinical practice but is my own opinion based on the available current research evidence and my clinical expertise and experience. Clinicians should consider if this advice is appropriate for them and use their own reasoning processes considering the individual patient in question

The Clinical Translator from PhysioEducators : "striving for excellence through innovation in Physio Education.”

Thank you to Ewa Roos and all the staff at Southern Denmark University for hosting me and sharing their current research projects. One exciting project we discussed is “The Dream Trial”, being conducted by Associate Professor Soren Skou together with Associate Professor Jonas Thorlund.

I met with Associate Professor Jonas Thorlund, from the Department of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy to discuss “The Dream Trial”. The Dream Trial is is a random controlled trial comparing meniscal surgery with a combined exercise and education program, for young people with confirmed meniscal injury. Their hypothesis is that patients randomised to surgery will improve significantly more in pain, function and quality of life after 12 months than those randomised to exercise and patient education.

Arthroscopic surgery is a very common orthopaedic procedure. While several trials have investigated the effect of knee arthroscopy for middle-aged and older patients with meniscal tears, there is a paucity of trials comparing meniscal surgery with non-surgical treatment for younger adults. The aim of this randomised controlled trial (RCT) is to investigate if early arthroscopic surgery is superior to exercise therapy and education, with the option of later surgery if needed, in improving pain, function and quality of life in younger adults with meniscal tears.

Methods and analysis

This is a protocol for a multicentre, parallel-group RCT conducted at six hospitals across all five healthcare regions in Denmark. 140 patients aged 18–40 years with a clinical history and symptoms consistent witha meniscal tear, verified on MRI, found eligible for meniscal surgery by an orthopaedic surgeon will be randomly allocated to one of two groups (1:1 ratio). Participants randomised to surgery will undergo either arthroscopic partial meniscectomy or meniscal repair followed by standard postsurgical care, while participants allocated to exercise and education will undergo a 12-week individualised, supervised neuromuscular and strengthening exercise programme and patient education. The primary outcome will be differencein change from baseline to 12 months in the mean score on four Knee Injury and Osteoarthritis Outcome Score subscales, covering pain, symptoms, function in sports and recreation and quality of life (Knee Injury and Osteoarthritis Outcome Score (KOOS4)) supported by the individual subscale scores allowing clinical interpretation. Alongside, the RCT an observational cohort will follow patients aged 18–40 years with clinical suspicion of a meniscal tear, but not fully eligible or declining to participate in the trial.

Ethics and dissemination

Results will be presented in peer-reviewed journals and at international conferences. This study is approved by the Regional Committees on Health Research Ethics for Southern Denmark. Registration details ClinicalTrials.gov (NCT02995551).

Starr and Dream Trials

The Starr Trial is a similar project to the Dream Trial. It is being conducted at Erasmus Medical Centre, Rotterdam by Dr Sussan Eijgenraam. The Starr Trial is an RCT looking at

Outcomes of the treatment groups will be collected at 2 years including pain / function as measured by the IKDC. KOOS, WOMET, Lysholm, NRS, EQ-5D scores and cost effectiveness. T2 mapping MRI’s comparing cartilage quality across the groups and histology studies in the surgical group are also being reported. Preliminary data collected has shown that some traumatic tears may have some pre existing degenerative changes in the cartilage.

The Clinical Translator:

We now have data to show arthroscopic partial meniscectomy was not superior to sham surgery in people with a degenerative medial meniscal tear with no OA (Fidelity Study, 2015 ). Katz et al (2013) also showed partial meniscectomy and physical therapy was not superior to physical therapy alone for people with a degenerative meniscus tear and OA. To date there are no studies on young people with meniscal tears comparing non-operative and operative management.

The Dream and the Starr study are important research projects to inform us of treatment options for younger people with meniscal tears / pathology. As a clinician I think it is important to read the inclusion and exclusion criteria to understand the applicability of results to an individual patient. The inclusion criteria for both studies (* see full text) are broad and includes many young people I would see with a meniscal injury. The exclusion of the Dream study: previous knee surgery / major knee ligament ruptures/ acute locked knee/ displaced bucket handle tear/ fractures in that lower limb in past 6/12. The Starr study exclusion criteria are similar but also excludes repairable meniscal tears as confirmed on MRI and other co-morbidities. The exercise program of the Dream study was tested in a pilot trial and consisted of initial range of movement exercises and swelling control, followed by strength endurance and neuromuscular training gradually progressed to hypertrophy training. An education program accompanied the training program.

This is intended as an aid to the clinician to translate research findings into clinical practice but is my own opinion based on the available current research evidence and my clinical expertise and experience. Clinicians should consider if this advice is appropriate for them and use their own reasoning processes considering the individual patient in question

The Clinical Translator from PhysioEducators : "striving for excellence through innovation in Physio Education."

Another important study discussed with Max Reijman whilst I was visiting Erasmus in Rotterdam was “Degenerative changes in the Knee 2 years after ACL ligament rupture and related risk factors”. Belle L Van Meer was the primary author.

Erasmus Medical Centre

I have attached the abstract from The American Journal of Sports Medicine 44(6) March 2016:

Abstract

Background: Anterior cruciate ligament (ACL) rupture is a well-known risk factor for development of knee osteoarthritis. Early identification of those patients at risk and early identification of the process of ACL rupture leading to osteoarthritis may aid in preventing the onset or progression of osteoarthritis.

Purpose: To identify early degenerative changes as assessed on magnetic resonance imaging (MRI) after 2-year follow-up in patients with a recent ACL rupture and to evaluate which determinants are related to these changes.

Study design: Cohort study; Level of evidence, 2.

Methods: Included in this study were 154 adults aged between 18 and 45 years with acute ACL rupture diagnosed by physical examination and MRI, without previous knee trauma or surgery, and without osteoarthritic changes on radiographs. A total of 143 patients completed the 2-year follow-up, and the results in this study apply to these 143 patients. All patients were treated according to the Dutch guideline on ACL injury. Of the 143 patients, 50 patients were treated non-operatively during the 2-year follow-up period.

Main outcome was early degenerative changes assessed on MRI defined as progression of cartilage defects and osteophytes in tibiofemoral and patellofemoral compartments. Patient characteristics, activity level, functional instability, treatment type, and trauma-related variables were evaluated as determinants.

Results: The median time between MRI at baseline and MRI at 2-year follow-up was 25.9 months (interquartile range, 24.7-26.9 months). Progression of cartilage defects in the medial and lateral tibiofemoral compartments was present in 12% and 27% of patients, and progression of osteophytes in tibiofemoral and patellofemoral compartments was present in 10% and 8% of patients, respectively. The following determinants were positively significantly associated with early degenerative changes: male sex (odds ratio [OR], 4.43; 95% CI, 1.43-13.66; P = .010), cartilage defect in the medial tibiofemoral compartment at baseline (OR, 3.66; 95% CI, 1.04-12.95; P = .044), presence of bone marrow lesions in the medial tibiofemoral compartment 1 year after trauma (OR, 5.19; 95% CI, 1.56-17.25; P = .007), joint effusion 1 year after trauma (OR, 4.19; 95% CI, 1.05-16.72; P = .042), and presence of meniscal tears (OR, 6.37; 95% CI, 1.94-20.88; P = .002). When the patients were categorized into 3 treatment groups (non operative, reconstruction <6 months after ACL rupture, and reconstruction ≥6 months after ACL rupture), there was no significant relationship between the treatment options and the development of early degenerative changes.

Conclusion: Two years after ACL rupture, early degenerative changes were assessed on MRI. Concomitant medial cartilage defect and meniscal injury, male sex, persistent bone marrow lesions in the medial tibiofemoral compartment, and joint effusion are risk factors for degenerative changes.

The Clinical Translator: Anterior Cruciate Ligament injuries result in degenerative change and associated symptoms in approximately 50% of affected knees at 10-15 years post injury. This study found early degenerative change at 2 years post injury in several subgroups including those people who had:

As clinicians, sports physicians and surgeons working with these people it would seem imperative to monitor symptoms carefully, especially in the above mentioned sub-groups during the rehab phase, optimise muscle strength / power whilst respecting joint symptoms and possibly delaying high impact loading. In a shared decision-making model this depends on the desired outcome expressed by the patient–early return to high level / elite sport OR optimising long term knee quality of life/ possibly slowing joint degenerative change.

No significant relationship was found between the treatment options (non-operative versus operative) and the development of early degenerative changes.

Interestingly in this cohort study, 50 of 154 patients were managed non-operatively (35%). The Dutch guidelines advise delaying surgical opinion for ACL reconstruction for a period of 3 months post injury, during which time quads exercises and general activity are encouraged.

Another study by Van Meer et al, attached below, found bone density loss in the injured knee following ACL injury, particularly in the operated group and in the first year post ACLR. This is another important consideration for clinicians when deciding appropriate timing of high load plyometric exercises.

This is intended as an aid to the clinician to translate research findings into clinical practice but is my own opinion based on the available current research evidence and my clinical expertise and experience. Clinicians should consider if this advice is appropriate for them and use their own reasoning processes considering the individual patient in question

The Clinical Translator from PhysioEducator: "striving for excellence through innovation in Physio Education”

Another important study which followed this one also by Belle L van Meer et al, looked at bone density loss after ACL injury:

Objective: The pathophysiology of anterior cruciate ligament (ACL) rupture leading to knee osteoarthritis (OA) remains largely unknown. It seems that bone loss occurs after ACL rupture. The purpose of our study was to determine bone mineral density (BMD) changes in the knee after ACL rupture during 2-year follow-up period and to compare BMD changes between the injured and healthy contralateral knee.

Design: Patients were included in an observational prospective follow-up study within 6 months after ACL trauma and evaluated for 2 years. Patients were treated operatively or non-operatively. At baseline and at the one- and 2-year follow-ups, BMD was measured in six regions of the tibia and femur for both knees (medial, central, lateral) using a Dual-energy X-ray Absorptiometry (DXA) scanner.

Results: One hundred forty-one patients were included, with the following characteristics: 66% were male, median age at baseline was 25.3 (inter-quartile range 11.3) years, and 63% were treated operatively. After 1 year, BMD was significantly lower in all regions of the injured knee of the operatively treated patients compared to baseline. After 2 years, BMD was significantly increased, but remained lower than the baseline levels. In all regions for all measurements, the mean BMD was significantly lower in the injured knee than in the healthy contralateral knee.

Conclusions: During a 2-year follow-up period after ACL rupture, the BMD level in the injured knee was found to be lower than in the healthy contralateral knee. In operatively treated patients, the BMD decreased in the first year and increased in the second follow-up year.

I met with Dr Vincent Eggerding, MD, who is a researcher in Sports Medicine, Traumatology and Orthopaedic Surgery for the Dept of Orthopaedics at Erasmus MC. He has published an interesting paper on knee joint shape possibly predicting clinical outcome after ACL ligament rupture. You can read the abstract in Bone and Joint Journal, 96-B(6) : 737-42, June 2014.

Statistical shape modelling was used to measure the shape of the knee joint in 182 patients after ACL rupture. Knee shape was then associated with International Knee Committee Subjective Scores (IKDC) at 2 years follow up. They found that 2 shapes were significantly associated with subjective score at 2 years, one for the operative group and one for the non- operative group.

Operative patients who scored better on the IDKC at 2 years had a smaller intercondylar notch and a smaller width of the intercondylar eminence.

Non-operative patients who scored better on the IDKC at 2 years had a more pyramidal intercondylar notch as opposed to a more dome shaped notch.

The Clinical Translator : The bony shape of the knee is a fixed non-modifiable factor which may influence outcome post ACL injury and subsequent success of either operative or non-operative management. The authors of this study found at least 30 different shape variations of the knee joint reminding us of individual anatomical variability. Knee joint shape may play a role in inherent knee joint stability and influence ACL injury outcomes. The Clinician must remember though it is only one of many important factors when considering ACL injury outcomes.

**This is intended as an aid to the clinician to translate research findings into clinical practice but is my own opinion based on the available current research evidence and my clinical expertise and experience. Clinicians should consider if this advice is appropriate for them and use their own reasoning processes considering the individual patient in question.

The Clinical Translator from PhysioEducators : "striving for excellence through innovation in Physio Education”

I am loving my journey through Europe as part of my Churchill Fellowship Award. Not only am I learning a lot from each of the experts I am meeting with, I'm picking up knowledge about Winston Churchill himself!

Did you know Churchill invented the 'onesie' in 1930? Back then it was known as the 'siren suit', although he liked to refer to it as his 'romper suit'. Apparently he had many different shades of velvet rompers. You know what they say about fashion cycles!

The Compare Study is a very exciting project currently being conducted at Erasmus Medical Centre, Rotterdam. I met with Dr Max Reijman, Physiotherapist and Primary Investigator and Dr Duncan Meuffels, Orthopaedic Surgeon to discuss this trial.

The Compare Trial is comparing non-operative and operative management effectiveness for ACL injury. This randomised trial has similar inclusion and exclusion criteria and rehab protocols to the KANON trial (conducted by Frobel et al, 2010) and has a 2 year follow up period, using the IKDC score as an outcome measure. A secondary aim of this project is to compare cost effectiveness of the 2 management options.

Final data collection for this trial is almost completed but watch out for the results over the next six months, as will add to our knowledge base of evidence based treatment selection for ACL injured patients.

Dr Reijman discussed the advantages and disadvantages of each treatment option. Please see a summary below:

The Clinical Translator: Guidelines in The Netherlands for ACL injury recommends that GPs wait for three months before a surgical referral is indicated. During this time exercise and physical activity is recommended. Imaging is only recommended if presenting with a locked knee or if a fracture is suspected.

As many of you are aware the Kanon trial (Frobel et al, 2010) showed at two and five years there was little difference in outcomes (KOOS score, Tegner activity Scale and Medical Outcome Study 36) between the 3 groups; rehabilitation alone, early reconstruction and rehabilitation and delayed reconstruction if required.

This is the only RCT which has been done to date comparing these treatment groups for ACL injury so we look forward to The Compare Study to see if the Kanon results are repeated.

I am also interested in the 10 year Kanon results with respect to OA, meniscal tear and instability rates so we can start to understand the long term implications of treatment options for our ACL patients.

It is my opinion that patients need to be well informed of the advantages and disadvantages of each treatment option so they can make an informed decision re an appropriate individually tailored management plan with short and long term risks and benefits considered.

This is intended as an aid to the clinician to translate research findings into clinical practice but is my own opinion based on the available current research evidence and my clinical expertise and experience. Clinicians should consider if this advice is appropriate for them and use their own reasoning processes considering the individual patient in question

I visited the amazing research team today at Erasmus Medical Centre. This recently re built academic teaching hospital in Rotterdam has 11,000 staff, including a large medical research faculty. This is the largest Medical Centre in the Netherlands and houses a children’s hospital, main multi trauma centre and medical school, the education centre of which has won several design awards.

I was fortunate to meet with Dr Max Reijman, Physiotherapist, who is the primary investigator of many projects at Erasmus Medical Centre. We discussed appropriate patient completed outcome questionnaires to measure impairment post ACL injury.

As a clinician working closely with this population I would encourage you to read this abstract. I have previously been using the Knee Injury and Osteoarthritis Outcome Score (KOOS) as with many clinicians and researchers in the ACL field, but this publication challenges using this in the early stage post ACL injury.

The full article can be accessed in Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 29, No 4 (April), 2013: pp 701-715.

Purpose: To evaluate which questionnaire, the Knee Injury and Osteoarthritis Outcome Score (KOOS) or the International Knee Documentation Committee Subjective Knee Form (IKDC subjective), is most useful to evaluate patients with recent anterior cruciate ligament (ACL) ruptures or those within 1 year of an ACL reconstruction.

Methods: Patients with recent (0-6 months) ACL ruptures or those with indications for ACL reconstruction were included. All patients completed the questionnaires shortly after trauma or preoperatively and again 1 year later. The KOOS has 5 subscales, each scored separately. The IKDC subjective consists of one total score. The following measurement properties of the KOOS and IKDC subjective were assessed: content validity (n 1⁄4 45), construct validity (n 1⁄4 100), test-retest reliability (n 1⁄4 50), and responsiveness (n 1⁄4 50).

Results: Regarding content validity, 2 KOOS subscales (Pain and Activities of Daily Living) were scored as nonrelevant. Two of the 18 questions on the IKDC subjective were assessed as nonrelevant. Only the KOOS subscale Sport and Recreation Function had acceptable construct validity (79% confirmation of the predefined hypotheses). None of the KOOS subscales had a sufficient score for responsiveness (<75% confirmation of the predefined hypotheses). The IKDC subjective scored acceptable for construct validity (84% confirmation of the predefined hypotheses) and responsiveness (86% confirmation of the predefined hypotheses). All KOOS subscales and the IKDC subjective had a reliability (intraclass correlation coefficient [ICC]) of 0.81 or higher.

Conclusions: The IKDC subjective is more useful than the KOOS questionnaire to evaluate both patients with recent ACL ruptures and those in the first year after ACL reconstruction. Level of Evidence: Level III, prognostic validation study.

The Clinical Translator: Monitoring a patient’s progress post ACL injury is important regardless of the management selected. Patient completed questionnaires assist to provide a more accurate insight to the patient’s perception of their knee function following ACL injury and can be used at intervals during the recovery period to evaluate progress.

The short and long-term effects of an ACL injury on a patients knee function differ. This research indicates the International Documentation Knee Committee Score (IKDC) may be more appropriate to use in the first 12-18 months post ACL injury as compared to the KOOS. The IKDC Knee forms are freely available on the AOSSM web site.

Interestingly my last blog discussed the ACL-QOL scored highest as endorsed by ACL patients compared to both the IKDC and the KOOS, however the IKDC was also rated favourably by ACL deficient patients.

This is intended as an aid to the clinician to translate research findings into clinical practice but is my own opinion based on the available current research evidence and my clinical expertise and experience. Clinicians should consider if this advice is appropriate for them and use their own reasoning processes considering the individual patient in question

The Clinical Translator from PhysioEducators: "striving for excellence through innovation in Physio Education”

ACL injury has both short and long term effects on the knee itself and the person as a whole.

Another interesting point of discussion with Dr Steph Filbay in London was appropriate questionnaires to assess the patient's perception of the impact of ACL injury and management, on their knee quality of life.

This has been compared to other knee specific quality of Life instruments in a trial published by Tanner et al, in The American Journal of Sports Medicine, Vol. 35, No. 9 , 2007 You can access the full article including the ACL-QOL questionnaire here.

They found the Mohtadi QOL scored highest as endorsed by patients with an ACL injury as compared to IKDC, KOOS, HSS, Cincinnati, Lysholm, VAS, ADL and AAOS.

Watch out also for Steph Filbay et al publication coming soon in JOSPT looking at long term Quality of Life outcomes after ACL injury.

The Clinical Translator (my notes): Sometimes as clinicians we focus primarily on objective clinical testing rather than combining this with the patients perception of their injury experience or management progress. The ACL- QOL (which is a patient completed questionnaire) is a simple valid, reliable and responsive tool ( Lafave et al, 2017). It can allow us to have greater insights into the impact an ACL injury is having on that individual person and their life including symptoms and physical complaints, work-related concerns, recreational activities and sport participation or competition, lifestyle and social and emotional effects. This information is very relevant in a shared decision making model utilising a biopsychosocial approach and can be used to monitor management progress.

This is intended as an aid to the clinician to translate research findings into clinical practice but is my own opinion based on the available current research evidence and my clinical expertise and experience. Clinicians should consider if this advice is appropriate for them and use their own reasoning processes considering the individual patient in question

Had a great meeting with Stephanie Filbay in London yesterday discussing prognostic factors post-ACL injury.

I would encourage you to read the paper available on Open Access if you are a physio, doctor, or surgeon working in this area. More knowledge of the findings from this paper and the ACL injury subgroups which exist by service providers could help us to be closer to providing world best practice of anterior cruciate ligament injury in Australia. It’s been a great week in London so far and a great start to my Churchill Fellowship!

The Clinical Translator (my comments on the paper):

Patients presenting with an acute ACL injury + baseline meniscal / osteochondral injury / more severe knee pain, swelling and /or impaired function may benefit from undertaking physiotherapy involving an exercise program initially, before considering the need for surgical reconstruction. This ensures more successful outcomes for both the patient but also the surgeon if surgery is required.

This is intended as an aid to the clinician to translate research findings into clinical practice but is my own opinion based on the available current research evidence and my clinical expertise and experience. Clinicians should consider if this advice is appropriate for them and use their own reasoning processes considering the individual patient in question

The Clinical Translator from PhysioEducators : "striving for excellence through innovation in Physio Education”

I travelled to Blenheim Palace in Oxfordshire to see Winston Churchill’s grand birthplace and his final modest resting place nearby in the village of Bladon.

A Churchill quote resonated with me at this time: "Courage is rightly esteemed the first of human qualities because it is the quality which guarantees all others." This quality was certainly important during the Fellowship application process but more importantly during the Fellowship and the implementation process.